Use of Flap versus Graft in Urethroplasty for Urethral Stricture: A Systematic Review and Meta-Analysis

Use of Flap versus Graft in Urethroplasty for Urethral Stricture: A Systematic Review and Meta-Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Use of Flap versus Graft in Urethroplasty for Urethral Stricture: A Systematic Review and Meta-Analysis Michelangelo Cobangbang, Nadia Dorca, Rano Matta, Sarah Neu, Amanda Chung, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9486919/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Purpose To compare functional and perioperative outcomes of urethroplasty using flap versus graft techniques in the management of urethral strictures, evaluating success rate, urinary flow, perioperative outcomes, patient-reported satisfaction, and complications to determine the relative effectiveness and safety of these reconstructive approaches. Methods PubMed, EMBASE, Scopus, and the Cochrane Library were searched for studies comparing flap versus graft urethroplasty in adult males. Outcomes included success rate, operative time, hospital stay, Qmax, patient satisfaction, and complications. Random-effects models were used to calculate odds ratios (ORs) for dichotomous data and mean differences (MDs) for continuous data. Analysis was performed using Review Manager. The study was registered in PROSPERO (CRD42020197405). Results Twenty-three studies (n = 1,787; 803 flap, 984 graft) were included. Grafts showed higher patient satisfaction (OR 2.60, 95% CI 1.05–6.40; P = 0.04) and fewer late complications (OR 1.84, 95% CI 1.33–2.53; P = 0.0002). No significant differences were found in success rate (OR 0.99; P = 0.94), operative time (MD 19.86; P = 0.07), Qmax (MD 0.06; P = 0.96), Qmax < 15 mL/s (OR 0.66; P = 0.41), hospital stay (MD 0.01; P = 0.97), or early complications (OR 1.03; P = 0.90). Conclusion Flap and graft urethroplasty yield comparable functional and perioperative outcomes. Grafts are associated with higher patient satisfaction and fewer late complications, suggesting advantages in long-term, patient-centered outcomes when appropriately selected. Urethral Stricture Urethroplasty Flap Graft Substitution Urethroplasty Augmentation Urethroplasty Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Urethral stricture disease (USD) is a prevalent condition involving fibrotic narrowing of the urethra caused by spongiofibrosis that leads to bladder outlet obstruction [ 1 ]. It primarily affects men due to the anatomy of the male urethra and carries significant clinical and economic burden due to its chronic, recurrent nature [ 1 , 2 ]. Globally, USD affects approximately 0.6–1% of men, with incidence rates of 229–627 per 100,000 [ 3 ]. Causes include iatrogenic injury (e.g., catheterization, endoscopic procedures, prostate surgery), trauma, inflammatory conditions such as lichen sclerosus, and infections, though etiology has shifted from predominantly infectious to largely iatrogenic and idiopathic [ 4 , 5 ]. USD management ranges from endoscopic treatments (dilation, direct visual internal urethrotomy) to definitive urethroplasty. Although minimally invasive and widely used, endoscopic methods have high recurrence rates, especially for long or complex strictures [ 6 ]. Urethroplasty with grafts or flaps is preferred for long, recurrent, or multifocal anterior strictures, as it restores urethral caliber over extended segments, provides durable outcomes, and avoids repeated treatment failure [ 7 ]. Flaps are used for complex proximal strictures due to their robust blood supply and resistance to contracture, while grafts, particularly buccal mucosa, are preferred for anterior strictures because of easy harvest, favorable properties, low donor morbidity, and high success rates [ 8 , 9 , 10 ]. Current guidelines stress individualized selection: grafts suit most anterior strictures, whereas flaps are reserved for cases with poor local tissue or blood supply or when single-stage tubularization is needed [ 2 , 6 ]. This systematic review and meta-analysis seek to gather the most recent information on flap versus graft usage in USD, assessing surgical outcomes, complication rates, and long-term efficacy for long and complex urethral strictures. PATIENTS AND METHODS Study Design This study aimed to evaluate the effectiveness, safety, and clinical results related to both surgical methods in the repair of USD through a systematic review and meta-analysis. The review protocol was documented in the International Prospective Register of Systematic Reviews (PROSPERO) registry (CRD42020197405) and carried out following Cochrane Collaboration guidelines [ 11 ], ensuring that reporting complied with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [ 12 ]. Search Strategy A comprehensive literature search, conducted with a certified medical librarian, identified studies comparing surgical outcomes and complications between flap and graft techniques for USD. Databases searched included PubMed/MEDLINE, EMBASE, Scopus, and the Cochrane Library from inception to February 2025, without language restrictions. Grey literature (e.g., conference abstracts, unpublished studies) and ongoing and unpublished trials from ClinicalTrials.gov and ProQuest Dissertations and Theses were also included. The researchers used both Pubmed Medical Subject Heading (MeSH) terms and free text in all fields including title, abstracts, keywords (preliminary terms: (“urethral stricture”[All Fields] OR “urethral stenosis”[All Fields] OR "panurethral stricture"[All Fields] OR "panurethral stenosis"[All Fields]) AND (“surgical flaps”[All Fields] OR “skin transplantation”[All Fields] OR (((“surgical”[All Fields] OR “Byars’”[MeSH Terms] OR “Byars”[All Fields] OR “penile” [All fields] OR “island” [All fields] OR “pedicled” [All fields]) OR “flap” [All fields] OR “urethroplasty” [All fields] OR (“skin” [All fields] OR “derm” [All fields] OR “local skin” [All fields] OR “buccal” [All fields] OR “buccal mucosa” [All fields] OR “preputial” [All fields] OR “prepuce” [All fields] OR “urethral” [All fields] OR “split thickness” [All fields] OR “full thickness” [All fields]) OR “reconstruct” [All fields] OR “repair” [All fields] OR “graft” [All fields] OR “transplant” [All fields] OR “dermatoplast” [All fields] OR “dorsal onlay” [All fields])))). Reference lists of eligible studies, reviews, and textbooks were manually screened, and subject matter experts were consulted to identify additional or unpublished data. A supplementary search of PubMed/MEDLINE and Google Scholar (through 27 May 2025), along with citation tracking and prior systematic reviews, was conducted. All records were imported into reference management software, and duplicates were removed before screening. Study Selection Eligible studies were comparative human clinical studies in adults, including randomized or quasi-randomized trials, cohort studies, and relevant case series. The review focused on anterior urethral strictures > 2 cm not suitable for anastomotic urethroplasty, of varied etiologies (idiopathic, infectious, instrumentation- or catheter-related, lichen sclerosus, traumatic, iatrogenic, inflammatory, malignant), confirmed by imaging (retrograde urethrogram/voiding cystourethrogram) and/or cystourethroscopy. Patients with prior endoscopic or open interventions were included. Interventions comprised reconstructive flap and graft urethroplasty techniques using various materials (flaps: penile, preputial, scrotal skin, fasciocutaneous; grafts: buccal or lingual mucosa, penile skin, colonic or bladder mucosa). Studies were excluded if patients had unsuitable penile skin, oral mucosal disorders, combined flap–graft procedures, or female USD. Study selection was performed independently by two reviewers. Titles/abstracts and full texts were screened against predefined criteria, with disagreements resolved by consensus or adjudication by a senior reviewer. Data Extraction, Data Synthesis and Data Classification Data extraction was conducted by one reviewer and independently verified by a second. For multiple publications from the same cohort, the most recent and comprehensive report was included. A standardized extraction table captured study characteristics (author, year, design), patient demographics, stricture etiology, length and location, surgical technique, graft/flap material, and other relevant variables. When selective reporting or inconsistencies were suspected, corresponding authors were contacted for clarification or additional data, including missing effect estimates. Primary dichotomous outcomes included success rate, Qmax < 15 mL/sec, patient satisfaction, and early/late complications, summarized as odds ratios (ORs) with 95% confidence intervals (CIs). Continuous outcomes (operative time, Qmax, hospital stay) were pooled as mean differences (MDs) with 95% CIs. Variability in definitions of “success” across studies was accounted for. Means and standard deviations (SD) were extracted or derived from available data when necessary. Method-specific complications were described qualitatively due to heterogeneous reporting. Pooled estimates were calculated using an inverse-variance random-effects model, and analyses were performed using Review Manager (RevMan) version 5.4. Risk of Bias and Heterogeneity Assessment Methodological quality was assessed by study design using the ROBINS-I tool for non-randomized studies and the Cochrane RoB 2 tool for randomized trials, following domain-based frameworks. Two reviewers performed assessments independently, resolving disagreements by consensus. Results were visualized using the Robvis tool. RESULTS The literature search yielded 18,367 records. After removing 5,692 duplicates, 12,675 titles/abstracts were screened and 11,949 excluded. Of 726 full-text articles assessed, 703 were excluded (Fig. I), leaving 23 studies (9 randomized, 14 non-randomized) included for final analysis. These included 1,787 adult males with long-segment anterior USD. 803 underwent flap reconstruction and 984 graft urethroplasty. Study characteristics varied in age, stricture length and etiology, prior interventions, and follow-up, reflecting clinical heterogeneity (Table I). Flap techniques included penile skin, fasciocutaneous island, scrotal (Turner-Warwick), and Q-flaps; graft techniques included dorsal/ventral onlay and inlay, and tubularized approaches. Outcomes were assessed using clinical evaluation, symptom scores, urethrography/voiding cystourethrography, and cystourethroscopy . Study Quality Assessment (Risk of Bias) Among non-randomized studies (ROBINS-I), six had serious risk of bias (mainly baseline confounding) and eight had moderate risk, with concerns in selection, intervention classification, deviations, missing data, outcome measurement, and reporting (Supplementary Material I). Of the randomized trials (RoB 2), five had low risk, three had some concerns (e.g., allocation concealment, deviations, outcome selection), and one had high risk due to missing data and selective reporting (Supplementary Material II). Outcome Effect Estimates Success Rate All 23 studies assessed success rates for flap versus graft urethroplasty [9, 13-34] (Fig. II). Pooled analysis showed no significant difference between techniques (OR 0.99, 95% CI 0.76–1.29; P = 0.94), with low heterogeneity (I² = 0%). Definitions of success varied across studies, typically combining symptom improvement, uroflowmetry (most commonly Qmax >15 mL/s [13, 14, 23, 27-29, 30-33], though thresholds ranged from ≥10–15 mL/s [20,22]), absence of radiologic/endoscopic recurrence, and freedom from reintervention. Some studies relied primarily on lack of postoperative instrumentation, radiologic/endoscopic patency (RUG/cystoscopy), or symptom resolution [14, 16, 18, 19, 26, 29, 31, 33], while others used less clearly defined criteria. One study defined patency as the ability to pass a 16 Fr flexible cystoscope at follow-up [25]. Another study defined success simply as absence of recurrence, without specifying objective criteria [9]. This variability should be considered when interpreting pooled outcomes. Operative Time Operative time was reported in 10 studies [9, 14, 15, 19, 20, 23, 26, 28, 31, 32] (n=480: 230 flap, 250 graft). Pooled analysis showed no significant difference between techniques (MD 19.86, 95% CI −1.80 to 41.52; P=0.07), though flap procedures trended longer (Supplementary Material III). Heterogeneity was high (I²=97%; Tau² = 1148.57; df = 9, P < 0.00001), with inconsistent study findings likely reflecting differences in technique, stricture characteristics, and surgeon experience. Maximum Flow Rate Postoperative Qmax was reported in 7 studies [9, 14, 15, 20, 23, 28, 31] (n=351: 165 flap, 186 graft) and was comparable between groups (MD 0.06, 95% CI −2.23 to 2.35; P=0.96) with substantial heterogeneity (I²=84%; Tau² = 7.35; df = 6, P < 0.00001) and variable follow-up (6–56 months) (Supplementary Material IV). Similarly, the proportion of patients with Qmax <15 mL/s (3 studies [14, 23, 31]; n=196) showed no significant difference (OR 0.66, 95% CI 0.25–1.75; P=0.41) with no heterogeneity (I²=0%; Tau² = 0.00; df = 2, P = 0.46) (Supplementary Material V). Satisfaction Patient satisfaction was reported in 3 studies [9, 19, 32] (n=136: 67 flap, 69 graft) with statistically significant results favoring graft urethroplasty (OR 2.60, 95% CI 1.05–6.40; P=0.04), with no heterogeneity (I²=0%; Tau² = 0.00; df = 2, P = 0.38) (Fig. III). Hospital Stay Length of hospital stay was reported in 3 studies [9,28,32] (n=112: 55 flap, 57 graft) and results showed no difference (MD 0.01 days, 95% CI −0.74 to 0.77; P=0.97), though heterogeneity was substantial (I²=81%; Tau² = 0.35; df = 2, P = 0.005), with mixed individual results (Supplementary Material VI). Early Complications Early complications were reported in 14 studies [9, 14, 15, 18-21, 23, 25-27, 31-33] and showed no statistically significant difference between flap and graft urethroplasty (OR 1.03, 95% CI 0.66–1.62; P=0.90), with 50 versus 46 events, respectively and demonstrating no heterogeneity (I²=0%; Tau² = 0.00; df = 19, P = 0.83). Wound infection was reported in all 14 studies (n=880: 414 flap, 446 graft) and was similar between groups (OR 1.02, 95% CI 0.60–1.73; P=0.94; 38 vs 35 events; I²=0%). Hematoma was reported in 6 studies [9, 15, 19, 26, 27, 32] (n=421: 213 flap, 208 graft) which also showed no difference (OR 1.06, 95% CI 0.45–2.50; P=0.90; 12 vs 11 events; I²=0%). No subgroup differences were observed (P=0.94), indicating consistent effects across outcomes (Supplementary Material VII). Late Complications Late complications, defined as events appearing after the initial healing period, which is usually months to years postoperatively, were analyzed across 17 studies [13,15,17-21,23-27,30-34] and results were significantly higher with flap versus graft urethroplasty (OR 1.84, 95% CI 1.33–2.53; P=0.0002; 143 vs 104 events), with low heterogeneity (I²=11%; Tau² = 0.11; df = 39, P = 0.28) (Fig. IV). Subgroup Outcomes of Late Complications Fistula (15 studies; OR 2.26, 95% CI: 1.22 to 4.16, P=0.009), flap/graft necrosis (3 studies; OR 2.78, 95% CI: 1.38 to 5.61, P=0.004), urethral diverticulum (6 studies; OR 3.22, 95% CI: 1.28 to 8.08, P=0.01), and dehiscence (2 studies; OR 3.11, 95% CI: 1.16 to 8.32, P=0.02) were all significantly more frequent with flaps (Fig. IV). Erectile dysfunction (3 studies; OR 0.70, 95% CI: 0.19 to 2.66, P=0.61), recurrent UTI (2 studies; OR 0.43, 95% CI: 0.12 to 1.53, P=0.19), postvoid dribbling (6 studies; OR 1.69, 95% CI: 0.95 to 3.02, P=0.07), and penile curvature (5 studies; OR 0.60, 95% CI 0.10 to 3.58, P=0.58) showed no significant differences. Heterogeneity was minimal for most outcomes (I²≈0%) (Fig. IV). Overall, subgroup analysis showed no statistically significant difference between complication subtypes (P = 0.08), although the direction of effect consistently favored graft urethroplasty for several structural late complications. Procedure-Specific Complications Procedure-specific complications were reported descriptively. Grafts (especially buccal mucosa) were associated with oral morbidity (e.g., hypersalivation, numbness, limited mouth opening) and were reported in 34 of 239 patients (14.2%) across eight studies [9,14,19,20,23,31-33]. Flaps were linked to penile complications (e.g., torsion, hypoesthesia, skin necrosis), and were reported in 16 of 118 patients (13.6%) across three studies [15,19,32]. These findings indicate distinct morbidity profiles associated with grafts and flaps. Publication Bias Funnel plot inspection showed a largely symmetrical distribution around the pooled estimate, with no clear evidence of substantial publication bias (Supplementary Material VIII). Minor asymmetry among smaller studies was observed but did not suggest meaningful bias. However, this interpretation is limited by the subjective nature of visual assessment. DISCUSSION This meta-analysis found no significant differences between flap and graft urethroplasty in success rates, urinary flow, operative time, or hospital stay. However, grafts were associated with higher patient satisfaction and fewer late complications (e.g., fistula, necrosis, diverticulum, dehiscence), suggesting comparable functional efficacy but a more favorable long-term and patient-centered profile. Grafts may therefore be preferred when tissue quality and vascularity are adequate, while flaps remain useful in cases with poor vascularity, extensive spongiofibrosis, or complex recurrence [ 35 ]. Both techniques achieved similar urethral patency. Oral mucosal grafts (especially buccal) are commonly favored for their biological properties but depend on a well-vascularized bed [ 7 , 8 , 10 , 14 , 15 , 26 ], whereas pedicled flaps retain intrinsic blood supply and may be advantageous in long, obliterative, or scarred strictures [ 31 , 35 ]. This must be weighed against greater technical complexity and higher rates of penile morbidity with flaps [ 2 , 7 – 10 , 15 , 18 , 20 , 27 – 34 ]. Interpretation of equivalent success rates is limited by heterogeneity in outcome definitions [ 1 , 2 , 6 , 7 ]. Qmax outcomes were similar, suggesting urinary flow depends more on luminal restoration, residual fibrosis, and healing than on reconstructive method. Urine flow dynamics are probably affected more by the sufficiency of luminal enhancement, the level of remaining spongiofibrosis, and long-term healing traits rather than by the conduit being a graft or a flap itself [ 36 , 37 ]. Perioperative outcomes were also comparable. Flap procedures trended toward longer operative time, but findings were heterogeneous and likely influenced by surgical and patient factors [ 15 , 35 ]. Hospital stay did not differ, indicating similar early recovery, likely shaped by institutional practices rather than technique alone. Despite similar objective and perioperative outcomes, patient satisfaction favored graft urethroplasty, highlighting the limits of metrics such as Qmax or reintervention to assess the true success. Grafts, especially buccal mucosa, require less penile tissue manipulation, resulting in lower penile morbidity, less cosmetic change, and fewer issues such as torsion or altered sensation [ 38 , 39 ]. In contrast, flap reconstruction may cause donor-site scarring, bulkiness, and aesthetic changes that negatively affect perceived success despite acceptable function [ 20 , 32 ]. Early complications (e.g., infection, hematoma) were comparable, likely reflecting shared operative steps rather than tissue type. Early morbidity appears more influenced by stricture complexity, tissue quality, prior interventions, surgical technique, and patient factors, emphasizing the importance of surgical execution and perioperative care [ 6 , 40 , 41 ]. Flap urethroplasty showed higher late complication rates (e.g., fistula, necrosis, diverticulum, dehiscence), likely due to the technical and vascular demands of pedicled flaps and their bulkier structure, which may predispose to sacculation and postvoid issues [ 42 ]. Outcomes depend on precise pedicle handling, tension-free transfer, and adequate drainage. Failure can lead to ischemia and structural complications [ 15 , 25 , 39 ]. In contrast, grafts, particularly buccal mucosa, provide thin, resilient, hairless tissue that integrates well with a vascular bed, promoting stable healing and reducing long-term structural complications [ 10 , 43 ]. Procedure-specific trade-offs remain: flaps risk penile complications [ 7 , 8 , 39 ], while grafts may cause transient oral donor-site morbidity, typically without lasting effects [ 44 ]. This study provides a focused comparative synthesis of flap versus graft urethroplasty, incorporating multiple clinically relevant outcomes, including urinary flow, perioperative parameters, patient satisfaction, and early and late complications. Subgroup analyses of complications further clarify differences beyond overall success. Limitations include the predominance of non-randomized studies with potential selection bias and confounding, particularly as flap patients may have more complex disease. Significant clinical and methodological heterogeneity existed (e.g., stricture characteristics, prior treatments, techniques, follow-up), along with variable definitions of success. Some analyses relied on few studies, limiting power and increasing susceptibility to small-study effects. Additionally, included studies spanned decades, during which surgical techniques and practices have evolved. In summary, flap and graft urethroplasty yield comparable functional outcomes, but grafts show better long-term complication profiles and higher patient satisfaction. Lower rates of late structural complications support grafts as the preferred option when feasible, while flaps remain important for complex cases. Optimal outcomes depend on careful patient selection and technique tailoring. Further studies using standardized outcomes are needed. Declarations COMPETING INTERESTS Dr. Amanda Chung serves as a proctor for Medtronic, Boston Scientific, and Coloplast; has received speaker honoraria from Medtronic and Coloplast; is a clinical advisory board member for Medtronic; and serves as a trial investigator for Australis Scientific. All other authors declare no conflicts of interest. ETHICAL APPROVAL This study was granted an ethics exemption by the Institutional Ethics Review Committee of St. Luke’s Medical Center, Quezon City, Philippines (Approval No. SL-25367). FUNDING None. CONTRIBUTIONS M Cobangbang: Protocol/project development, Data collection, Data analysis, Manuscript Writing and Editing N Dorca: Data collection, Data analysis, Manuscript Writing R Matta: Data analysis, Manuscript Writing and Editing S Neu: Data analysis, Manuscript Writing and Editing A Chung: Data analysis, Manuscript Writing and Editing K McCammon: Manuscript Writing and Editing M Aubé-Peterkin: Data analysis, Manuscript Writing and Editing M Chua: Protocol/project development, Data collection, Data analysis, Manuscript Writing and Editing References Madec FX, Marcelli F, Neuville P, Fourel M, Baudry A, Morel-Journel N, Karsenty G. Urethral strictures - General aspects: Definition, anatomy of the urethra and its clinical application in stenosis, epidemiology, etiology, and principles of urethral reconstruction. Fr J Urol. 2024 Nov;34(11):102720. doi: 10.1016/j.fjurol.2024.102720. PMID: 39586660. Wessells H, Morey A, Souter L, Rahimi L, Vanni A. 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Buccal mucosa graft versus penile skin flap for the management of long segment anterior urethral strictures: Success rate and patients’ satisfaction. International Journal of Reconstructive Urology 1(2):p 68-73, May-August 2023. | DOI: 10.4103/IJRU.IJRU_11_23 Eziyi AK, Olajide AO, Etonyeaku AC, Ojewuyi OO, Eziyi JA, Adeyanju T, Adeyemo L. One-stage urethroplasty for urethral strictures at the Ladoke Akintola University of Technology Teaching Hospital, Osogbo, south western Nigeria. World J Surg. 2013 Nov;37(11):2529-33. doi: 10.1007/s00268-013-2176-5. PMID: 23942533. Fu Q, Zhang Y, Zhang J, Xie H, Sa YL, Jin S. Substitution urethroplasty for anterior urethral stricture repair: comparison between lingual mucosa graft and pedicled skin flap. Scand J Urol. 2017 Dec;51(6):479-483. doi: 10.1080/21681805.2017.1353541. Epub 2017 Jul 25. PMID: 28738760. Gupta M, Gupta H, Choyal A, Sadasukhi N, Sadasukhi T, Sharma A, Jat S. Local penile skin flap versus buccal mucosal graft urethroplasty for urethral stricture: a prospective randomized study. Int J Pharm Clin Res. 2024;16(10):252-256. Hosseini J, Soltanzadeh K. A comparative study of long-term results of Buccal Mucosal Graft and Penile Skin Flap techniques in the management of diffuse anterior urethral strictures: first report in Iran. Urol J. 2004 Spring;1(2):94-8. PMID: 17874393. Hoy NY, Chapman DW, Rourke KF. Better defining the optimal management of penile urethral strictures: A retrospective comparison of single-stage vs. two-stage urethroplasty. Can Urol Assoc J. 2019 Dec;13(12):414-418. doi: 10.5489/cuaj.5895. PMID: 31039110; PMCID: PMC6892683. Hussein MM, Moursy E, Gamal W, Zaki M, Rashed A, Abozaid A. The use of penile skin graft versus penile skin flap in the repair of long bulbo-penile urethral stricture: a prospective randomized study. Urology. 2011 May;77(5):1232-7. doi: 10.1016/j.urology.2010.08.064. Epub 2011 Jan 5. PMID: 21208648. Kessler TM, Schreiter F, Kralidis G, Heitz M, Olianas R, Fisch M. Long-term results of surgery for urethral stricture: a statistical analysis. J Urol. 2003 Sep;170(3):840-4. doi: 10.1097/01.ju.0000080842.99332.94. PMID: 12913712. Kumar N, Ahmad A, Upadhyay R, Tiwari RK, Mehmood K, Ranjan N. Comparative Study of the Outcome of Buccal Mucosa Graft Urethroplasty and Preputial Flap Urethroplasty for Anterior Urethral Stricture: A Prospective Randomized Study. Cureus. 2024 Mar 7;16(3):e55732. doi: 10.7759/cureus.55732. PMID: 38586660; PMCID: PMC10998686. Lumen N, Hoebeke P, Oosterlinck W. Urethroplasty for urethral strictures: quality assessment of an in-home algorithm. Int J Urol. 2010 Feb;17(2):167-74. doi: 10.1111/j.1442-2042.2009.02435.x. Epub 2010 Jan 12. PMID: 20070412. Sa YL, Xu YM, Qian Y, Jin SB, Fu Q, Zhang XR, Zhang J, Gu BJ. A comparative study of buccal mucosa graft and penile pedical flap for reconstruction of anterior urethral strictures. Chin Med J (Engl). 2010 Feb 5;123(3):365-8. PMID: 20193261. Singh RP, Jamal A. Circular Penile Skin Fasciocutaneous Ventral Onlay Flap Urethroplasty as an Alternative to Dorsal Onlay Buccal Mucosal Graft Urethroplasty in Complex Long-Segment Urethral Stricture: A Retrospective Study. Cureus. 2023 Sep 12;15(9):e45084. doi: 10.7759/cureus.45084. PMID: 37842454; PMCID: PMC10568655. Soliman MG, Abo Farha M, El Abd AS, Abdel Hameed H, El Gamal S. Dorsal onlay urethroplasty using buccal mucosa graft versus penile skin flap for management of long anterior urethral strictures: a prospective randomized study. Scand J Urol. 2014 Oct;48(5):466-73. doi: 10.3109/21681805.2014.888474. Epub 2014 Mar 3. PMID: 24579804. Tawakol A, Abdel-Rassoul M, Abdelwahab M, Elghoneimy M, Abdelaziz AY, Rammah A, et al. MP60-16 DORSAL/ DORSO-LATERAL ONLAY BUCCAL MUCOSAL GRAFT VERSUS VENTRAL ONLAY LOCAL PENILE SKIN FLAP IN COMPLEX ANTERIOR URETHRAL STRICTURES; A PROSPECTIVE RANDOMIZED STUDY. Journal of Urology [Internet]. 2023 Apr 1 [cited 2026 Mar 21];209(Supplement 4):e849. Available from: https://doi.org/10.1097/JU.0000000000003318.16 Xu YM, Qiao Y, Sa YL, Wu DL, Zhang XR, Zhang J, Gu BJ, Jin SB. Substitution urethroplasty of complex and long-segment urethral strictures: a rationale for procedure selection. Eur Urol. 2007 Apr;51(4):1093-8; discussion 1098-9. doi: 10.1016/j.eururo.2006.11.039. Epub 2006 Nov 27. PMID: 17157433. Joshi PM, Bandini M, Bafna S, Sharma V, Patil A, Bhadranavar S, Yepes C, Barbagli G, Montorsi F, Kulkarni SB. Graft Plus Fasciocutaneous Penile Flap for Nearly or Completely Obliterated Long Bulbar and Penobulbar Strictures. Eur Urol Open Sci. 2021 Nov 25;35:21-28. doi: 10.1016/j.euros.2021.10.009. PMID: 34877550; PMCID: PMC8633879. Wisenbaugh ES, Gelman J. The Use of Flaps and Grafts in the Treatment of Urethral Stricture Disease. Adv Urol. 2015;2015:979868. doi: 10.1155/2015/979868. Epub 2015 Nov 19. PMID: 26664357; PMCID: PMC4668293. Wong HPN, So WZ, Fong KY, Tiong HY, Kulkarni S, Castellani D, Somani B, Gauhar V. Advances in urethral stricture diagnostics and urethral reconstruction beyond traditional imaging: a scoping review. Cent European J Urol. 2024;77(3):528-537. doi: 10.5173/ceju.2024.121. Epub 2024 Sep 30. PMID: 40115474; PMCID: PMC11921950. Khan MU, Dawood M, Malhi MAD, Haider MH, Hussain A, Ali A, Qureshi S. Investigating the Outcomes and Complications of Urethroplasty Using Different Graft Materials in Men With Complex or Recurrent Urethral Strictures. Cureus. 2025 Jun 16;17(6):e86119. doi: 10.7759/cureus.86119. PMID: 40677476; PMCID: PMC12267606. Alrefaey, A., Anwar, M.A., Abdelmagid, M.E. et al. Comparative outcomes of penile skin grafts versus buccal mucosal grafts in urethroplasty for the treatment of extensive anterior urethral strictures. Sci Rep 15, 29508 (2025). https://doi.org/10.1038/s41598-025-14191-w Shkoukani ZW, Rauf A, Abdulmajed M, Omar A, Floyd MS Jr. Bridging Surgical Outcomes and Patient Experience: A Questionnaire-Based Evaluation of Buccal Mucosal Graft Morbidity Following Substitution Urethroplasty. Cureus. 2025 Oct 15;17(10):e94647. doi: 10.7759/cureus.94647. PMID: 41104027; PMCID: PMC12526711. Spilotros M, Sihra N, Malde S, Pakzad MH, Hamid R, Ockrim JL, Greenwell TJ. Buccal mucosal graft urethroplasty in men-risk factors for recurrence and complications: a third referral centre experience in anterior urethroplasty using buccal mucosal graft. Transl Androl Urol. 2017 Jun;6(3):510-516. doi: 10.21037/tau.2017.03.69. PMID: 28725593; PMCID: PMC5503967. Calvo CI, Bekkema J, Rourke KF. Prospective assessment of the incidence and associations of postvoid dribbling after urethroplasty Impact of surgical technique. Can Urol Assoc J. 2023 Oct;17(10):341-345. doi: 10.5489/cuaj.8360. PMID: 37494321; PMCID: PMC10581731. Alwaal A, Harris CR, Enriquez A, McAninch JW, Breyer BN. Healing of Donor-site Buccal Mucosa Urethroplasty. Urology. 2015 Sep;86(3):e9-e10. doi: 10.1016/j.urology.2015.06.032. Epub 2015 Jul 4. PMID: 26151892; PMCID: PMC4917202. Desai D, Joshi S, Ravichandran K, Flynn H, De Wachter S, De Win G. Donor site morbidity and impact on oral health following buccal mucosal graft harvesting for urethroplasty: a prospective study. World J Urol. 2025 Sep 2;43(1):531. doi: 10.1007/s00345-025-05898-6. PMID: 40897855. Table Table 1 is available in the supplementary files section Additional Declarations No competing interests reported. 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4","display":"","copyAsset":false,"role":"figure","size":535538,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eLate Complications forest plot\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-9486919/v1/1c059fd74faefdd4653dcfe8.png"},{"id":108979761,"identity":"70737487-870d-4a53-9ad3-d42a0df6f2f8","added_by":"auto","created_at":"2026-05-11 12:01:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1006864,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9486919/v1/a7a343be-e377-4482-8f3f-01cb5d1d3a21.pdf"},{"id":108945698,"identity":"bdf23c1c-ed36-4481-89fb-659132cf68f2","added_by":"auto","created_at":"2026-05-11 06:16:41","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":2293261,"visible":true,"origin":"","legend":"","description":"","filename":"TableIStrictureStudyBaselineCharacteristics.docx","url":"https://assets-eu.researchsquare.com/files/rs-9486919/v1/c3881976c0fad4912808dfe9.docx"},{"id":108945694,"identity":"29e70c32-f849-4573-880f-b5c293afa35f","added_by":"auto","created_at":"2026-05-11 06:16:41","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":7582274,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterialIROBINS.docx","url":"https://assets-eu.researchsquare.com/files/rs-9486919/v1/ea5ca1266be884552e5d6fb1.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Use of Flap versus Graft in Urethroplasty for Urethral Stricture: A Systematic Review and Meta-Analysis","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eUrethral stricture disease (USD) is a prevalent condition involving fibrotic narrowing of the urethra caused by spongiofibrosis that leads to bladder outlet obstruction [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It primarily affects men due to the anatomy of the male urethra and carries significant clinical and economic burden due to its chronic, recurrent nature [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Globally, USD affects approximately 0.6\u0026ndash;1% of men, with incidence rates of 229\u0026ndash;627 per 100,000 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Causes include iatrogenic injury (e.g., catheterization, endoscopic procedures, prostate surgery), trauma, inflammatory conditions such as lichen sclerosus, and infections, though etiology has shifted from predominantly infectious to largely iatrogenic and idiopathic [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. USD management ranges from endoscopic treatments (dilation, direct visual internal urethrotomy) to definitive urethroplasty. Although minimally invasive and widely used, endoscopic methods have high recurrence rates, especially for long or complex strictures [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Urethroplasty with grafts or flaps is preferred for long, recurrent, or multifocal anterior strictures, as it restores urethral caliber over extended segments, provides durable outcomes, and avoids repeated treatment failure [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Flaps are used for complex proximal strictures due to their robust blood supply and resistance to contracture, while grafts, particularly buccal mucosa, are preferred for anterior strictures because of easy harvest, favorable properties, low donor morbidity, and high success rates [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Current guidelines stress individualized selection: grafts suit most anterior strictures, whereas flaps are reserved for cases with poor local tissue or blood supply or when single-stage tubularization is needed [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis systematic review and meta-analysis seek to gather the most recent information on flap versus graft usage in USD, assessing surgical outcomes, complication rates, and long-term efficacy for long and complex urethral strictures.\u003c/p\u003e"},{"header":"PATIENTS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis study aimed to evaluate the effectiveness, safety, and clinical results related to both surgical methods in the repair of USD through a systematic review and meta-analysis. The review protocol was documented in the International Prospective Register of Systematic Reviews (PROSPERO) registry (CRD42020197405) and carried out following Cochrane Collaboration guidelines [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], ensuring that reporting complied with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSearch Strategy\u003c/h3\u003e\n\u003cp\u003eA comprehensive literature search, conducted with a certified medical librarian, identified studies comparing surgical outcomes and complications between flap and graft techniques for USD. Databases searched included PubMed/MEDLINE, EMBASE, Scopus, and the Cochrane Library from inception to February 2025, without language restrictions. Grey literature (e.g., conference abstracts, unpublished studies) and ongoing and unpublished trials from ClinicalTrials.gov and ProQuest Dissertations and Theses were also included.\u003c/p\u003e \u003cp\u003eThe researchers used both Pubmed Medical Subject Heading (MeSH) terms and free text in all fields including title, abstracts, keywords (preliminary terms: (\u0026ldquo;urethral stricture\u0026rdquo;[All Fields] OR \u0026ldquo;urethral stenosis\u0026rdquo;[All Fields] OR \"panurethral stricture\"[All Fields] OR \"panurethral stenosis\"[All Fields]) AND (\u0026ldquo;surgical flaps\u0026rdquo;[All Fields] OR \u0026ldquo;skin transplantation\u0026rdquo;[All Fields] OR (((\u0026ldquo;surgical\u0026rdquo;[All Fields] OR \u0026ldquo;Byars\u0026rsquo;\u0026rdquo;[MeSH Terms] OR \u0026ldquo;Byars\u0026rdquo;[All Fields] OR \u0026ldquo;penile\u0026rdquo; [All fields] OR \u0026ldquo;island\u0026rdquo; [All fields] OR \u0026ldquo;pedicled\u0026rdquo; [All fields]) OR \u0026ldquo;flap\u0026rdquo; [All fields] OR \u0026ldquo;urethroplasty\u0026rdquo; [All fields] OR (\u0026ldquo;skin\u0026rdquo; [All fields] OR \u0026ldquo;derm\u0026rdquo; [All fields] OR \u0026ldquo;local skin\u0026rdquo; [All fields] OR \u0026ldquo;buccal\u0026rdquo; [All fields] OR \u0026ldquo;buccal mucosa\u0026rdquo; [All fields] OR \u0026ldquo;preputial\u0026rdquo; [All fields] OR \u0026ldquo;prepuce\u0026rdquo; [All fields] OR \u0026ldquo;urethral\u0026rdquo; [All fields] OR \u0026ldquo;split thickness\u0026rdquo; [All fields] OR \u0026ldquo;full thickness\u0026rdquo; [All fields]) OR \u0026ldquo;reconstruct\u0026rdquo; [All fields] OR \u0026ldquo;repair\u0026rdquo; [All fields] OR \u0026ldquo;graft\u0026rdquo; [All fields] OR \u0026ldquo;transplant\u0026rdquo; [All fields] OR \u0026ldquo;dermatoplast\u0026rdquo; [All fields] OR \u0026ldquo;dorsal onlay\u0026rdquo; [All fields])))).\u003c/p\u003e \u003cp\u003eReference lists of eligible studies, reviews, and textbooks were manually screened, and subject matter experts were consulted to identify additional or unpublished data. A supplementary search of PubMed/MEDLINE and Google Scholar (through 27 May 2025), along with citation tracking and prior systematic reviews, was conducted. All records were imported into reference management software, and duplicates were removed before screening.\u003c/p\u003e\n\u003ch3\u003eStudy Selection\u003c/h3\u003e\n\u003cp\u003eEligible studies were comparative human clinical studies in adults, including randomized or quasi-randomized trials, cohort studies, and relevant case series. The review focused on anterior urethral strictures\u0026thinsp;\u0026gt;\u0026thinsp;2 cm not suitable for anastomotic urethroplasty, of varied etiologies (idiopathic, infectious, instrumentation- or catheter-related, lichen sclerosus, traumatic, iatrogenic, inflammatory, malignant), confirmed by imaging (retrograde urethrogram/voiding cystourethrogram) and/or cystourethroscopy. Patients with prior endoscopic or open interventions were included.\u003c/p\u003e \u003cp\u003eInterventions comprised reconstructive flap and graft urethroplasty techniques using various materials (flaps: penile, preputial, scrotal skin, fasciocutaneous; grafts: buccal or lingual mucosa, penile skin, colonic or bladder mucosa). Studies were excluded if patients had unsuitable penile skin, oral mucosal disorders, combined flap\u0026ndash;graft procedures, or female USD.\u003c/p\u003e \u003cp\u003eStudy selection was performed independently by two reviewers. Titles/abstracts and full texts were screened against predefined criteria, with disagreements resolved by consensus or adjudication by a senior reviewer.\u003c/p\u003e\n\u003ch3\u003eData Extraction, Data Synthesis and Data Classification\u003c/h3\u003e\n\u003cp\u003eData extraction was conducted by one reviewer and independently verified by a second. For multiple publications from the same cohort, the most recent and comprehensive report was included. A standardized extraction table captured study characteristics (author, year, design), patient demographics, stricture etiology, length and location, surgical technique, graft/flap material, and other relevant variables. When selective reporting or inconsistencies were suspected, corresponding authors were contacted for clarification or additional data, including missing effect estimates.\u003c/p\u003e \u003cp\u003ePrimary dichotomous outcomes included success rate, Qmax\u0026thinsp;\u0026lt;\u0026thinsp;15 mL/sec, patient satisfaction, and early/late complications, summarized as odds ratios (ORs) with 95% confidence intervals (CIs). Continuous outcomes (operative time, Qmax, hospital stay) were pooled as mean differences (MDs) with 95% CIs. Variability in definitions of \u0026ldquo;success\u0026rdquo; across studies was accounted for.\u003c/p\u003e \u003cp\u003eMeans and standard deviations (SD) were extracted or derived from available data when necessary. Method-specific complications were described qualitatively due to heterogeneous reporting. Pooled estimates were calculated using an inverse-variance random-effects model, and analyses were performed using Review Manager (RevMan) version 5.4.\u003c/p\u003e\n\u003ch3\u003eRisk of Bias and Heterogeneity Assessment\u003c/h3\u003e\n\u003cp\u003eMethodological quality was assessed by study design using the ROBINS-I tool for non-randomized studies and the Cochrane RoB 2 tool for randomized trials, following domain-based frameworks. Two reviewers performed assessments independently, resolving disagreements by consensus. Results were visualized using the Robvis tool.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe literature search yielded 18,367 records. After removing 5,692 duplicates, 12,675 titles/abstracts were screened and 11,949 excluded. Of 726 full-text articles assessed, 703 were excluded (Fig. I), leaving 23 studies (9 randomized, 14 non-randomized) included for final analysis. These included 1,787 adult males with long-segment anterior USD. 803 underwent flap reconstruction and 984 graft urethroplasty. Study characteristics varied in age, stricture length and etiology, prior interventions, and follow-up, reflecting clinical heterogeneity (Table I). Flap techniques included penile skin, fasciocutaneous island, scrotal (Turner-Warwick), and Q-flaps; graft techniques included dorsal/ventral onlay and inlay, and tubularized approaches. Outcomes were assessed using clinical evaluation, symptom scores, urethrography/voiding cystourethrography, and cystourethroscopy .\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Quality Assessment (Risk of Bias)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong non-randomized studies (ROBINS-I), six had serious risk of bias (mainly baseline confounding) and eight had moderate risk, with concerns in selection, intervention classification, deviations, missing data, outcome measurement, and reporting (Supplementary Material I). Of the randomized trials (RoB 2), five had low risk, three had some concerns (e.g., allocation concealment, deviations, outcome selection), and one had high risk due to missing data and selective reporting (Supplementary Material II).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcome Effect Estimates\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSuccess Rate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll 23 studies assessed success rates for flap versus graft urethroplasty [9, 13-34] (Fig. II). Pooled analysis showed no significant difference between techniques (OR 0.99, 95% CI 0.76–1.29; P = 0.94), with low heterogeneity (I² = 0%). Definitions of success varied across studies, typically combining symptom improvement, uroflowmetry (most commonly Qmax \u0026gt;15 mL/s [13, 14, 23, 27-29, 30-33], though thresholds ranged from ≥10–15 mL/s [20,22]), absence of radiologic/endoscopic recurrence, and freedom from reintervention. Some studies relied primarily on lack of postoperative instrumentation, radiologic/endoscopic patency (RUG/cystoscopy), or symptom resolution [14, 16, 18, 19, 26, 29, 31, 33], while others used less clearly defined criteria. One study defined patency as the ability to pass a 16 Fr flexible cystoscope at follow-up [25]. Another study defined success simply as absence of recurrence, without specifying objective criteria [9]. This variability should be considered when interpreting pooled outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOperative Time\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOperative time was reported in 10 studies [9, 14, 15, 19, 20, 23, 26, 28, 31, 32] (n=480: 230 flap, 250 graft). Pooled analysis showed no significant difference between techniques (MD 19.86, 95% CI −1.80 to 41.52; P=0.07), though flap procedures trended longer (Supplementary Material III). Heterogeneity was high (I²=97%; Tau² = 1148.57; df = 9, P \u0026lt; 0.00001), with inconsistent study findings likely reflecting differences in technique, stricture characteristics, and surgeon experience.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaximum Flow Rate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePostoperative Qmax was reported in 7 studies [9, 14, 15, 20, 23, 28, 31] (n=351: 165 flap, 186 graft) and was comparable between groups (MD 0.06, 95% CI −2.23 to 2.35; P=0.96) with substantial heterogeneity (I²=84%; Tau² = 7.35; df = 6, P \u0026lt; 0.00001) and variable follow-up (6–56 months) (Supplementary Material IV). Similarly, the proportion of patients with Qmax \u0026lt;15 mL/s (3 studies [14, 23, 31]; n=196) showed no significant difference (OR 0.66, 95% CI 0.25–1.75; P=0.41) with no heterogeneity (I²=0%; Tau² = 0.00; df = 2, P = 0.46) (Supplementary Material V).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSatisfaction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatient satisfaction was reported in 3 studies [9, 19, 32] (n=136: 67 flap, 69 graft) with statistically significant results favoring graft urethroplasty (OR 2.60, 95% CI 1.05–6.40; P=0.04), with no heterogeneity (I²=0%; Tau² = 0.00; df = 2, P = 0.38) (Fig. III).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHospital Stay\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLength of hospital stay was reported in 3 studies [9,28,32] (n=112: 55 flap, 57 graft) and results showed no difference (MD 0.01 days, 95% CI −0.74 to 0.77; P=0.97), though heterogeneity was substantial (I²=81%; Tau² = 0.35; df = 2, P = 0.005), with mixed individual results (Supplementary Material VI).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEarly Complications\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEarly complications were reported in 14 studies [9, 14, 15, 18-21, 23, 25-27, 31-33] and showed no statistically significant difference between flap and graft urethroplasty (OR 1.03, 95% CI 0.66–1.62; P=0.90), with 50 versus 46 events, respectively and demonstrating no heterogeneity (I²=0%; Tau² = 0.00; df = 19, P = 0.83). Wound infection was reported in all 14 studies (n=880: 414 flap, 446 graft) and was similar between groups (OR 1.02, 95% CI 0.60–1.73; P=0.94; 38 vs 35 events; I²=0%). Hematoma was reported in 6 studies [9, 15, 19, 26, 27, 32] (n=421: 213 flap, 208 graft) which also showed no difference (OR 1.06, 95% CI 0.45–2.50; P=0.90; 12 vs 11 events; I²=0%). No subgroup differences were observed (P=0.94), indicating consistent effects across outcomes (Supplementary Material VII).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLate Complications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLate complications, defined as events appearing after the initial healing period, which is usually months to years postoperatively, were analyzed across 17 studies [13,15,17-21,23-27,30-34] and results were significantly higher with flap versus graft urethroplasty (OR 1.84, 95% CI 1.33–2.53; P=0.0002; 143 vs 104 events), with low heterogeneity (I²=11%; Tau² = 0.11; df = 39, P = 0.28) (Fig. IV).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubgroup Outcomes of Late Complications\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFistula (15 studies; OR 2.26, 95% CI: 1.22 to 4.16, P=0.009), flap/graft necrosis (3 studies; OR 2.78, 95% CI: 1.38 to 5.61, P=0.004), urethral diverticulum (6 studies; OR 3.22, 95% CI: 1.28 to 8.08, P=0.01), and dehiscence (2 studies; OR 3.11, 95% CI: 1.16 to 8.32, P=0.02) were all significantly more frequent with flaps (Fig. IV). Erectile dysfunction (3 studies; OR 0.70, 95% CI: 0.19 to 2.66, P=0.61), recurrent UTI (2 studies; OR 0.43, 95% CI: 0.12 to 1.53, P=0.19), postvoid dribbling (6 studies; OR 1.69, 95% CI: 0.95 to 3.02, P=0.07), and penile curvature (5 studies; OR 0.60, 95% CI 0.10 to 3.58, P=0.58) showed no significant differences.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHeterogeneity was minimal for most outcomes (I²≈0%) (Fig. IV). Overall, subgroup analysis showed no statistically significant difference between complication subtypes (P = 0.08), although the direction of effect consistently favored graft urethroplasty for several structural late complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcedure-Specific Complications\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eProcedure-specific complications were reported descriptively. Grafts (especially buccal mucosa) were associated with oral morbidity (e.g., hypersalivation, numbness, limited mouth opening) and were reported in 34 of 239 patients (14.2%) across eight studies [9,14,19,20,23,31-33]. Flaps were linked to penile complications (e.g., torsion, hypoesthesia, skin necrosis), and were reported in 16 of 118 patients (13.6%) across three studies [15,19,32]. These findings indicate distinct morbidity profiles associated with grafts and flaps.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePublication Bias\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunnel plot inspection showed a largely symmetrical distribution around the pooled estimate, with no clear evidence of substantial publication bias (Supplementary Material VIII). Minor asymmetry among smaller studies was observed but did not suggest meaningful bias. However, this interpretation is limited by the subjective nature of visual assessment.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis meta-analysis found no significant differences between flap and graft urethroplasty in success rates, urinary flow, operative time, or hospital stay. However, grafts were associated with higher patient satisfaction and fewer late complications (e.g., fistula, necrosis, diverticulum, dehiscence), suggesting comparable functional efficacy but a more favorable long-term and patient-centered profile. Grafts may therefore be preferred when tissue quality and vascularity are adequate, while flaps remain useful in cases with poor vascularity, extensive spongiofibrosis, or complex recurrence [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBoth techniques achieved similar urethral patency. Oral mucosal grafts (especially buccal) are commonly favored for their biological properties but depend on a well-vascularized bed [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], whereas pedicled flaps retain intrinsic blood supply and may be advantageous in long, obliterative, or scarred strictures [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. This must be weighed against greater technical complexity and higher rates of penile morbidity with flaps [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan additionalcitationids=\"CR28 CR29 CR30 CR31 CR32 CR33\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Interpretation of equivalent success rates is limited by heterogeneity in outcome definitions [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eQmax outcomes were similar, suggesting urinary flow depends more on luminal restoration, residual fibrosis, and healing than on reconstructive method. Urine flow dynamics are probably affected more by the sufficiency of luminal enhancement, the level of remaining spongiofibrosis, and long-term healing traits rather than by the conduit being a graft or a flap itself [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Perioperative outcomes were also comparable. Flap procedures trended toward longer operative time, but findings were heterogeneous and likely influenced by surgical and patient factors [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Hospital stay did not differ, indicating similar early recovery, likely shaped by institutional practices rather than technique alone.\u003c/p\u003e \u003cp\u003eDespite similar objective and perioperative outcomes, patient satisfaction favored graft urethroplasty, highlighting the limits of metrics such as Qmax or reintervention to assess the true success. Grafts, especially buccal mucosa, require less penile tissue manipulation, resulting in lower penile morbidity, less cosmetic change, and fewer issues such as torsion or altered sensation [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. In contrast, flap reconstruction may cause donor-site scarring, bulkiness, and aesthetic changes that negatively affect perceived success despite acceptable function [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEarly complications (e.g., infection, hematoma) were comparable, likely reflecting shared operative steps rather than tissue type. Early morbidity appears more influenced by stricture complexity, tissue quality, prior interventions, surgical technique, and patient factors, emphasizing the importance of surgical execution and perioperative care [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFlap urethroplasty showed higher late complication rates (e.g., fistula, necrosis, diverticulum, dehiscence), likely due to the technical and vascular demands of pedicled flaps and their bulkier structure, which may predispose to sacculation and postvoid issues [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Outcomes depend on precise pedicle handling, tension-free transfer, and adequate drainage. Failure can lead to ischemia and structural complications [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. In contrast, grafts, particularly buccal mucosa, provide thin, resilient, hairless tissue that integrates well with a vascular bed, promoting stable healing and reducing long-term structural complications [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Procedure-specific trade-offs remain: flaps risk penile complications [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], while grafts may cause transient oral donor-site morbidity, typically without lasting effects [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study provides a focused comparative synthesis of flap versus graft urethroplasty, incorporating multiple clinically relevant outcomes, including urinary flow, perioperative parameters, patient satisfaction, and early and late complications. Subgroup analyses of complications further clarify differences beyond overall success.\u003c/p\u003e \u003cp\u003eLimitations include the predominance of non-randomized studies with potential selection bias and confounding, particularly as flap patients may have more complex disease. Significant clinical and methodological heterogeneity existed (e.g., stricture characteristics, prior treatments, techniques, follow-up), along with variable definitions of success. Some analyses relied on few studies, limiting power and increasing susceptibility to small-study effects. Additionally, included studies spanned decades, during which surgical techniques and practices have evolved.\u003c/p\u003e \u003cp\u003eIn summary, flap and graft urethroplasty yield comparable functional outcomes, but grafts show better long-term complication profiles and higher patient satisfaction. Lower rates of late structural complications support grafts as the preferred option when feasible, while flaps remain important for complex cases. Optimal outcomes depend on careful patient selection and technique tailoring. Further studies using standardized outcomes are needed.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCOMPETING INTERESTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr. Amanda Chung serves as a proctor for Medtronic, Boston Scientific, and Coloplast; has received speaker honoraria from Medtronic and Coloplast; is a clinical advisory board member for Medtronic; and serves as a trial investigator for Australis Scientific. All other authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eETHICAL APPROVAL\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was granted an ethics exemption by the Institutional Ethics Review Committee of St. Luke’s Medical Center, Quezon City, Philippines (Approval No. SL-25367).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFUNDING\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONTRIBUTIONS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eM Cobangbang: Protocol/project development, Data collection, Data analysis, Manuscript Writing and Editing\u003c/p\u003e\n\u003cp\u003eN Dorca: Data collection, Data analysis, Manuscript Writing\u003c/p\u003e\n\u003cp\u003eR Matta: Data analysis, Manuscript Writing and Editing\u003c/p\u003e\n\u003cp\u003eS Neu: Data analysis, Manuscript Writing and Editing\u003c/p\u003e\n\u003cp\u003eA Chung: Data analysis, Manuscript Writing and Editing\u003c/p\u003e\n\u003cp\u003eK McCammon: Manuscript Writing and Editing\u003c/p\u003e\n\u003cp\u003eM Aubé-Peterkin: Data analysis, Manuscript Writing and Editing\u003c/p\u003e\n\u003cp\u003eM Chua: Protocol/project development, Data collection, Data analysis, Manuscript Writing and Editing\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eMadec FX, Marcelli F, Neuville P, Fourel M, Baudry A, Morel-Journel N, Karsenty G. Urethral strictures - General aspects: Definition, anatomy of the urethra and its clinical application in stenosis, epidemiology, etiology, and principles of urethral reconstruction. Fr J Urol. 2024 Nov;34(11):102720. doi: 10.1016/j.fjurol.2024.102720. PMID: 39586660.\u003c/li\u003e\n \u003cli\u003eWessells H, Morey A, Souter L, Rahimi L, Vanni A. Urethral Stricture Disease Guideline Amendment (2023). J Urol. 2023 Jul;210(1):64-71. doi: 10.1097/JU.0000000000003482. Epub 2023 Apr 25. PMID: 37096574.\u003c/li\u003e\n \u003cli\u003eGul A, Ekici O, Zengin S, Barali D, Keskin T. Investigation of risk factors in the development of recurrent urethral stricture after internal urethrotomy. World J Clin Cases. 2024 May 16;12(14):2324-2331. doi: 10.12998/wjcc.v12.i14.2324. PMID: 38765734; PMCID: PMC11099401.\u003c/li\u003e\n \u003cli\u003ede Farias RB, Neto FTL, de Aguiar Cavalcanti G, Martins FE, Lima SVC. Evaluation of the etiological profile, age and findings in retrograde and voiding urethrocystography of men with urethral stricture. Sci Rep. 2025 Feb 18;15(1):5935. doi: 10.1038/s41598-025-89389-z. PMID: 39966429; PMCID: PMC11836406.\u003c/li\u003e\n \u003cli\u003eLumen N, Hoebeke P, Willemsen P, et al. Etiology of urethral stricture disease in the 21st century. Nat Rev Urol. 2021.\u003c/li\u003e\n \u003cli\u003eEuropean Association of Urology. (2025). EAU guidelines on urethral strictures [Edn. presented at the EAU Annual Congress Madrid 2025]. European Association of Urology.\u003c/li\u003e\n \u003cli\u003eSong L, Zhang R, Lu C, Chen Y. Factors to Consider in Augmentation Urethroplasty with Oral Mucosa Graft or Penile Skin Flap for Anterior Urethral Stricture: A Systematic Review and Meta-analysis. Eur Urol Open Sci. 2023 Mar 9;50:113-122. doi: 10.1016/j.euros.2023.02.010. PMID: 36942323; PMCID: PMC10023910.\u003c/li\u003e\n \u003cli\u003eMa Y, Jian ZY, Hu Q, Luo Z, Jin T. Oral Mucosa vs. Penile Skin Flap in Substitution Urethroplasty for Anterior Urethral Strictures: A Systematic Review and Meta-Analysis. Front Surg. 2021 Dec 23;8:803750. doi: 10.3389/fsurg.2021.803750. PMID: 35004838; PMCID: PMC8732363.\u003c/li\u003e\n \u003cli\u003eSayedahmed K, Omar M, Rosenhammer B, Burger M, Go\u0026szlig;ler C. Onlay Pedicled Transverse Skin Flap versus One-Stage Inlay Buccal Mucosal Graft in Penile Urethroplasty: A Prospective Matched-Pair Analysis. Urol Int. 2023;107(4):383-389. doi: 10.1159/000523958. Epub 2022 Apr 5. PMID: 35381596\u003c/li\u003e\n \u003cli\u003eCampos-Juanatey F, Azueta Etxebarria A, Calleja Hermosa P, Marcos Gonzalez S, Alonso Mediavilla E, Correas Gomez MA, Portillo Martin JA, Gutierrrez Ba\u0026ntilde;os JL. Histological Comparison of Buccal and Lingual Mucosa Grafts for Urethroplasty: Do They Share Tissue Structures and Vascular Supply? J Clin Med. 2022 Apr 6;11(7):2064. doi: 10.3390/jcm11072064. 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Cent European J Urol. 2019;72(2):191-197. doi: 10.5173/ceju.2019.1899. Epub 2019 Jun 29. PMID: 31482029; PMCID: PMC6715090.\u003c/li\u003e\n \u003cli\u003eAlsagheer GA, Fathi A, Abdel-Kader MS, Hasan AM, Mohamed O, Mahmoud O, Abolyosr A. Management of long segment anterior urethral stricture (\u0026ge; 8cm) using buccal mucosal (BM) graft and penile skin (PS) flap: outcome and predictors of failure. Int Braz J Urol. 2018 Jan-Feb;44(1):163-171. doi: 10.1590/S1677-5538.IBJU.2017.0083. PMID: 29211404; PMCID: PMC5815547.\u003c/li\u003e\n \u003cli\u003eBarbagli G, Morgia G, Lazzeri M. Retrospective outcome analysis of one-stage penile urethroplasty using a flap or graft in a homogeneous series of patients. BJU Int. 2008 Sep;102(7):853-60. doi: 10.1111/j.1464-410X.2008.07741.x. Epub 2008 May 15. Erratum in: BJU Int. 2008 Dec;102(11):1772. PMID: 18485036.\u003c/li\u003e\n \u003cli\u003eBoccon-Gibod L, Le Portz B. One-stage urethroplasty for urethral stricture. Free full thickness skin graft versus cutaneous island flap urethroplasty. Eur Urol. 1984;10(1):32-5. doi: 10.1159/000463507. PMID: 6365570.\u003c/li\u003e\n \u003cli\u003eClaassen, F., Wentzel, S. The treatment of complex urethral strictures using ventral onlay Buccal Mucosa Graft or ventral onlay penile Skin Island Flap urethroplasty: A prospective case series. Afr J Urol 17, 79\u0026ndash;84 (2011). https://doi.org/10.1007/s12301-011-0015-1\u003c/li\u003e\n \u003cli\u003eDubey D, Vijjan V, Kapoor R, Srivastava A, Mandhani A, Kumar A, Ansari MS. Dorsal onlay buccal mucosa versus penile skin flap urethroplasty for anterior urethral strictures: results from a randomized prospective trial. J Urol. 2007 Dec;178(6):2466-9. doi: 10.1016/j.juro.2007.08.010. Epub 2007 Oct 15. PMID: 17937943.\u003c/li\u003e\n \u003cli\u003eElmenair, Ali Mohamed; El-Hefnawy, Ahmed Sobhy; Wadie, Bassem S. Buccal mucosa graft versus penile skin flap for the management of long segment anterior urethral strictures: Success rate and patients\u0026rsquo; satisfaction. International Journal of Reconstructive Urology 1(2):p 68-73, May-August 2023. | DOI: 10.4103/IJRU.IJRU_11_23\u003c/li\u003e\n \u003cli\u003eEziyi AK, Olajide AO, Etonyeaku AC, Ojewuyi OO, Eziyi JA, Adeyanju T, Adeyemo L. One-stage urethroplasty for urethral strictures at the Ladoke Akintola University of Technology Teaching Hospital, Osogbo, south western Nigeria. World J Surg. 2013 Nov;37(11):2529-33. doi: 10.1007/s00268-013-2176-5. PMID: 23942533.\u003c/li\u003e\n \u003cli\u003eFu Q, Zhang Y, Zhang J, Xie H, Sa YL, Jin S. Substitution urethroplasty for anterior urethral stricture repair: comparison between lingual mucosa graft and pedicled skin flap. Scand J Urol. 2017 Dec;51(6):479-483. doi: 10.1080/21681805.2017.1353541. Epub 2017 Jul 25. PMID: 28738760.\u003c/li\u003e\n \u003cli\u003eGupta M, Gupta H, Choyal A, Sadasukhi N, Sadasukhi T, Sharma A, Jat S. Local penile skin flap versus buccal mucosal graft urethroplasty for urethral stricture: a prospective randomized study. Int J Pharm Clin Res. 2024;16(10):252-256.\u003c/li\u003e\n \u003cli\u003eHosseini J, Soltanzadeh K. A comparative study of long-term results of Buccal Mucosal Graft and Penile Skin Flap techniques in the management of diffuse anterior urethral strictures: first report in Iran. Urol J. 2004 Spring;1(2):94-8. PMID: 17874393.\u003c/li\u003e\n \u003cli\u003eHoy NY, Chapman DW, Rourke KF. Better defining the optimal management of penile urethral strictures: A retrospective comparison of single-stage vs. two-stage urethroplasty. Can Urol Assoc J. 2019 Dec;13(12):414-418. doi: 10.5489/cuaj.5895. PMID: 31039110; PMCID: PMC6892683.\u003c/li\u003e\n \u003cli\u003eHussein MM, Moursy E, Gamal W, Zaki M, Rashed A, Abozaid A. The use of penile skin graft versus penile skin flap in the repair of long bulbo-penile urethral stricture: a prospective randomized study. Urology. 2011 May;77(5):1232-7. doi: 10.1016/j.urology.2010.08.064. Epub 2011 Jan 5. PMID: 21208648.\u003c/li\u003e\n \u003cli\u003eKessler TM, Schreiter F, Kralidis G, Heitz M, Olianas R, Fisch M. Long-term results of surgery for urethral stricture: a statistical analysis. J Urol. 2003 Sep;170(3):840-4. doi: 10.1097/01.ju.0000080842.99332.94. PMID: 12913712.\u003c/li\u003e\n \u003cli\u003eKumar N, Ahmad A, Upadhyay R, Tiwari RK, Mehmood K, Ranjan N. Comparative Study of the Outcome of Buccal Mucosa Graft Urethroplasty and Preputial Flap Urethroplasty for Anterior Urethral Stricture: A Prospective Randomized Study. Cureus. 2024 Mar 7;16(3):e55732. doi: 10.7759/cureus.55732. PMID: 38586660; PMCID: PMC10998686.\u003c/li\u003e\n \u003cli\u003eLumen N, Hoebeke P, Oosterlinck W. Urethroplasty for urethral strictures: quality assessment of an in-home algorithm. Int J Urol. 2010 Feb;17(2):167-74. doi: 10.1111/j.1442-2042.2009.02435.x. Epub 2010 Jan 12. PMID: 20070412.\u003c/li\u003e\n \u003cli\u003eSa YL, Xu YM, Qian Y, Jin SB, Fu Q, Zhang XR, Zhang J, Gu BJ. A comparative study of buccal mucosa graft and penile pedical flap for reconstruction of anterior urethral strictures. Chin Med J (Engl). 2010 Feb 5;123(3):365-8. PMID: 20193261.\u003c/li\u003e\n \u003cli\u003eSingh RP, Jamal A. Circular Penile Skin Fasciocutaneous Ventral Onlay Flap Urethroplasty as an Alternative to Dorsal Onlay Buccal Mucosal Graft Urethroplasty in Complex Long-Segment Urethral Stricture: A Retrospective Study. Cureus. 2023 Sep 12;15(9):e45084. doi: 10.7759/cureus.45084. PMID: 37842454; PMCID: PMC10568655.\u003c/li\u003e\n \u003cli\u003eSoliman MG, Abo Farha M, El Abd AS, Abdel Hameed H, El Gamal S. Dorsal onlay urethroplasty using buccal mucosa graft versus penile skin flap for management of long anterior urethral strictures: a prospective randomized study. Scand J Urol. 2014 Oct;48(5):466-73. doi: 10.3109/21681805.2014.888474. Epub 2014 Mar 3. PMID: 24579804.\u003c/li\u003e\n \u003cli\u003eTawakol A, Abdel-Rassoul M, Abdelwahab M, Elghoneimy M, Abdelaziz AY, Rammah A, et al. MP60-16\u0026emsp;DORSAL/ DORSO-LATERAL ONLAY BUCCAL MUCOSAL GRAFT VERSUS VENTRAL ONLAY LOCAL PENILE SKIN FLAP IN COMPLEX ANTERIOR URETHRAL STRICTURES; A PROSPECTIVE RANDOMIZED STUDY. Journal of Urology [Internet]. 2023 Apr 1 [cited 2026 Mar 21];209(Supplement 4):e849. Available from: https://doi.org/10.1097/JU.0000000000003318.16\u003c/li\u003e\n \u003cli\u003eXu YM, Qiao Y, Sa YL, Wu DL, Zhang XR, Zhang J, Gu BJ, Jin SB. Substitution urethroplasty of complex and long-segment urethral strictures: a rationale for procedure selection. Eur Urol. 2007 Apr;51(4):1093-8; discussion 1098-9. doi: 10.1016/j.eururo.2006.11.039. Epub 2006 Nov 27. PMID: 17157433.\u003c/li\u003e\n \u003cli\u003eJoshi PM, Bandini M, Bafna S, Sharma V, Patil A, Bhadranavar S, Yepes C, Barbagli G, Montorsi F, Kulkarni SB. Graft Plus Fasciocutaneous Penile Flap for Nearly or Completely Obliterated Long Bulbar and Penobulbar Strictures. Eur Urol Open Sci. 2021 Nov 25;35:21-28. doi: 10.1016/j.euros.2021.10.009. PMID: 34877550; PMCID: PMC8633879.\u003c/li\u003e\n \u003cli\u003eWisenbaugh ES, Gelman J. The Use of Flaps and Grafts in the Treatment of Urethral Stricture Disease. Adv Urol. 2015;2015:979868. doi: 10.1155/2015/979868. Epub 2015 Nov 19. PMID: 26664357; PMCID: PMC4668293.\u003c/li\u003e\n \u003cli\u003eWong HPN, So WZ, Fong KY, Tiong HY, Kulkarni S, Castellani D, Somani B, Gauhar V. Advances in urethral stricture diagnostics and urethral reconstruction beyond traditional imaging: a scoping review. Cent European J Urol. 2024;77(3):528-537. doi: 10.5173/ceju.2024.121. Epub 2024 Sep 30. PMID: 40115474; PMCID: PMC11921950.\u003c/li\u003e\n \u003cli\u003eKhan MU, Dawood M, Malhi MAD, Haider MH, Hussain A, Ali A, Qureshi S. Investigating the Outcomes and Complications of Urethroplasty Using Different Graft Materials in Men With Complex or Recurrent Urethral Strictures. Cureus. 2025 Jun 16;17(6):e86119. doi: 10.7759/cureus.86119. PMID: 40677476; PMCID: PMC12267606.\u003c/li\u003e\n \u003cli\u003eAlrefaey, A., Anwar, M.A., Abdelmagid, M.E. et al. Comparative outcomes of penile skin grafts versus buccal mucosal grafts in urethroplasty for the treatment of extensive anterior urethral strictures. Sci Rep 15, 29508 (2025). https://doi.org/10.1038/s41598-025-14191-w\u003c/li\u003e\n \u003cli\u003eShkoukani ZW, Rauf A, Abdulmajed M, Omar A, Floyd MS Jr. Bridging Surgical Outcomes and Patient Experience: A Questionnaire-Based Evaluation of Buccal Mucosal Graft Morbidity Following Substitution Urethroplasty. Cureus. 2025 Oct 15;17(10):e94647. doi: 10.7759/cureus.94647. PMID: 41104027; PMCID: PMC12526711.\u003c/li\u003e\n \u003cli\u003eSpilotros M, Sihra N, Malde S, Pakzad MH, Hamid R, Ockrim JL, Greenwell TJ. Buccal mucosal graft urethroplasty in men-risk factors for recurrence and complications: a third referral centre experience in anterior urethroplasty using buccal mucosal graft. Transl Androl Urol. 2017 Jun;6(3):510-516. doi: 10.21037/tau.2017.03.69. PMID: 28725593; PMCID: PMC5503967.\u003c/li\u003e\n \u003cli\u003eCalvo CI, Bekkema J, Rourke KF. Prospective assessment of the incidence and associations of postvoid dribbling after urethroplasty Impact of surgical technique. Can Urol Assoc J. 2023 Oct;17(10):341-345. doi: 10.5489/cuaj.8360. PMID: 37494321; PMCID: PMC10581731.\u003c/li\u003e\n \u003cli\u003eAlwaal A, Harris CR, Enriquez A, McAninch JW, Breyer BN. Healing of Donor-site Buccal Mucosa Urethroplasty. Urology. 2015 Sep;86(3):e9-e10. doi: 10.1016/j.urology.2015.06.032. Epub 2015 Jul 4. PMID: 26151892; PMCID: PMC4917202.\u003c/li\u003e\n \u003cli\u003eDesai D, Joshi S, Ravichandran K, Flynn H, De Wachter S, De Win G. Donor site morbidity and impact on oral health following buccal mucosal graft harvesting for urethroplasty: a prospective study. World J Urol. 2025 Sep 2;43(1):531. doi: 10.1007/s00345-025-05898-6. PMID: 40897855.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003eTable 1 is available in the supplementary files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjur","sideBox":"Learn more about [World Journal of Urology](https://link.springer.com/journal/345)","snPcode":"345","submissionUrl":"https://submission.nature.com/new-submission/345/3","title":"World Journal of Urology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Urethral Stricture, Urethroplasty, Flap, Graft, Substitution Urethroplasty, Augmentation Urethroplasty","lastPublishedDoi":"10.21203/rs.3.rs-9486919/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9486919/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo compare functional and perioperative outcomes of urethroplasty using flap versus graft techniques in the management of urethral strictures, evaluating success rate, urinary flow, perioperative outcomes, patient-reported satisfaction, and complications to determine the relative effectiveness and safety of these reconstructive approaches.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003ePubMed, EMBASE, Scopus, and the Cochrane Library were searched for studies comparing flap versus graft urethroplasty in adult males. Outcomes included success rate, operative time, hospital stay, Qmax, patient satisfaction, and complications. Random-effects models were used to calculate odds ratios (ORs) for dichotomous data and mean differences (MDs) for continuous data. Analysis was performed using Review Manager. The study was registered in PROSPERO (CRD42020197405).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTwenty-three studies (n\u0026thinsp;=\u0026thinsp;1,787; 803 flap, 984 graft) were included. Grafts showed higher patient satisfaction (OR 2.60, 95% CI 1.05\u0026ndash;6.40; P\u0026thinsp;=\u0026thinsp;0.04) and fewer late complications (OR 1.84, 95% CI 1.33\u0026ndash;2.53; P\u0026thinsp;=\u0026thinsp;0.0002). No significant differences were found in success rate (OR 0.99; P\u0026thinsp;=\u0026thinsp;0.94), operative time (MD 19.86; P\u0026thinsp;=\u0026thinsp;0.07), Qmax (MD 0.06; P\u0026thinsp;=\u0026thinsp;0.96), Qmax\u0026thinsp;\u0026lt;\u0026thinsp;15 mL/s (OR 0.66; P\u0026thinsp;=\u0026thinsp;0.41), hospital stay (MD 0.01; P\u0026thinsp;=\u0026thinsp;0.97), or early complications (OR 1.03; P\u0026thinsp;=\u0026thinsp;0.90).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eFlap and graft urethroplasty yield comparable functional and perioperative outcomes. Grafts are associated with higher patient satisfaction and fewer late complications, suggesting advantages in long-term, patient-centered outcomes when appropriately selected.\u003c/p\u003e","manuscriptTitle":"Use of Flap versus Graft in Urethroplasty for Urethral Stricture: A Systematic Review and Meta-Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-11 06:16:25","doi":"10.21203/rs.3.rs-9486919/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-04T16:09:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"38913545741485191223363688423253741216","date":"2026-05-04T07:28:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"161207968230730731276235484166017398472","date":"2026-04-29T03:38:33+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-28T17:39:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-28T11:49:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-28T11:49:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"World Journal of Urology","date":"2026-04-21T15:51:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjur","sideBox":"Learn more about [World Journal of Urology](https://link.springer.com/journal/345)","snPcode":"345","submissionUrl":"https://submission.nature.com/new-submission/345/3","title":"World Journal of Urology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"015cfa8b-0b91-4547-a371-cfc08a800ed6","owner":[],"postedDate":"May 11th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-04T16:09:28+00:00","index":13,"fulltext":""},{"type":"reviewerAgreed","content":"38913545741485191223363688423253741216","date":"2026-05-04T07:28:02+00:00","index":12,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T06:16:25+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-11 06:16:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9486919","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9486919","identity":"rs-9486919","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}